Infectious Disease Flashcards
-What are physcial exam changes, vital sign changes, or lab abnormalities that present in sepsis and septic shock?
- Physical exam-delayed cap refill, AMS, cool mottled extremities
- Vital sign-fever, tachycardia, tachypnea, hypoxia, hypotension
- Lab-any sign of end organ damage as in elevated creatinine, hyperbili or elevated LFTs, elevated INR, abnormal leukocyte count (high or low) or band neutrophilia >10%
What are the SIRS criteria and how should you use them?
- systemic inflammatory response syndrome criteria, these are a clue that something is wrong. If a patient is suspected of having an infection and has atleast 2 SIRS criteria, presume sepsis until proven otherwise
- 4 Criteria:
1) fever or hypothermia
2) tachycaria or bradycardia
3) tachypnea or requiring mechanical ventilation
4) abnormal leukocyte count (high or low) or band neutrophilia >10
What is the “sepsis bundle” to always remember for any suspected septic patient?
-Culture, bolus, and antibiotics within the first hour of arrival
What labwork should be obtained in patients with suspected sepsis vs septic shock?
-blood+urine culture, CBC w/diff, loaded gas, POCT glucose, BMP+Hepatic panel, Coags, type and cross
- How should fluids be administered during septic shock?
- When should you consider using a vasoactive medication?
- Give up to 60 mL/kg of NS boluses within the first hour and start D10NS at maintenance.
- Fluid boluses of 20/kg should be given until evidence of fluid overload or shock reversal occurs.
- At 40mL/kg you should consider starting a vasoactive medication to acheive perfusion and consider giving blood if Hgb is <10mg/dL
How should antibiotics be administered during sepsis vs septic shock?
- give broad spectrum vanc+rocephin
- Add clinda if there is evidence of toxic shock
- Replace rocephin with cefepime if patient is immunocompromised
- Replace rocephin with zosyn vs meropenem if there is a suspected GI source
- Replace rocephin with meropenem if there is a documented penicillin allergy
- When should you consider giving pressors in sepsis vs septic shock?
- What pressors should you use?
- how are these medications dosed?
- if you’ve given at least 1x 20mL/kg (but usually at 40mL/kg) NS bolus and there is no clinical change
- For WARM shock (flash cap refill+bounding pulses, cardiac dysfxn likely 2/2 decreased vascular tone) give norepinephrine
- For COLD shock (delayed cap refill, diminished pulses, skin mottling, cardiac dysfxn likely 2/2 preload vs afterload vs contractility defect) give epinephrine
- Both are dosed as 0.05-0.1 mcg/kg/min and during shock can be given through a PIV
- During sepsis vs septic shock, when should you consider hydrocortisone?
- What dosing should you use?
- Any shock refractory to pressors
- For younger than toddlers give 50mg IV
- For toddlers and up give 100mg IV
- During sepsis vs septic shock when should you consider intubation?
- What drugs would you use for RSI?
- Consider for anyone undergoing respiratory distress refractory to NIPPV
- For sedative use ketamine+atropine
- For paralytic use succinylcholine, or rocuronium if succinylcholine is contraindicated
When should you consider giving tamiflu?
- Flu positive patient <2yo whose symptoms began <48 hours ago
- Consider giving to those >2yo or >/=48 duration of symptoms if patient is medically fragile or pt with severe symptoms
- What are the 3 Cs of early measles?
- What oral manifestation may be present?
- What is the rash of measles?
- Conjunctivitis, coryza, cough
- Koplic spots, white spots along the buccal mucosa
- Morbilliform rash-“eggs on the head” looks like erythematous and macular leasions
What is the causative agent and 2 forms of meningococcemia?
- neisseria meningitidis
- septic form (worse prognosis) and meningitic form
What is the presentation of meningococcemia?
3mo-5yo vs adolescent with history of URI sxs that decompensated and now has lethargy, HA, fever, vomiting, purpuric rash over the trunk and sepsis
What complications can happen with meningococcemia and what workup should be done if it is suspected?
- adrenal hemorrhage (waterhouse freiderichson syndrome), DIC, sepsis
- WU-culture the lesions, csf, blood. Gram stain will show gram - diplococci
How should meningococcemia be managed?
- Tx with rocephin+vanc, tx complications of hypoglycemia, thrombocytopenia, anemia, hypotension
- All providers will need prophylaxis
What organisms commonly cause meningitis in the following age groups?
- 0-28 days
- 1-3 months
- > 3mos
- 0-28 days-GBS, E. Coli, listeria, HSV
- 1-3 months-GBS, E coli, Hib, S pneumo, neisseria
- > 3mos-S pneumo, neisseria
What are signs and symptoms that should clue you into the possibility of necrotizing fasciitis?
- Patient with a soft tissue infection with pain out of proportion to exam, hemorrhagic bullae, edema, crepitus, erythema
- half of patients present without fever and half present without a clear portal of entry, so have a high index of suspicion
What will workup show with nec fasciitis?
-leukocytosis, hyponatremia, xray/CT showing gas tracking in the soft tissue
How should nec fasciitis be managed?
- If suspected immediate surgical consultation, time=tissue
- Mark the borders of involved tissue for comparison
- Tx with vanc, clinda (inactivate toxin), and zosyn
- How should pneumonia be treated by age group?
- When should chlamydia pneumonia be considered?
- <5yo amox vs amp
- > 5yo add azithro
- if disease is severe broaden to vanc and rocephin
- if a stacatto cough is heard in a 3wk-3mo consider chlamydia pneumonia and add on azithro
- What clinical criteria indicate admission for pneumonia?
- Which patients need PICU admission?
- admit anyone <6mos, hypoxia, febrile, tachypnic
- To PICU if sating <92% on >50% fiO2, apnic, exhaustion, AMS
What is the presentation and management of Roseola?
- 3-4 days of high fevers and decreased PO intake, once the fever resolves a maculopapular rash spreads from the trunk to the extremities
- supportive care
What are the centor criteria to consider strep pharyngitis as a ddx item?
- Tender cervical adenopathy
- High fevers
- Exudative pharyngitis
- Absence of cough
How should a strep pharyngitis infection be treated?
Tx with oral penicillin vs IM, give azithro if questionable allergy history
List potential complications of a strep infection.
- rheumatic fever
- scarlet fever
- strep toxic shock syndrome
- glomerulonephritis
- What is the clinical presentation of scarlet fever?
- What is the treatment?
- What anticipatory guidance should you tell parents about following treatment?
- erythematous sandpaper-like rash, pastia’s lines (hypopigmented lines within skin creases), strawberry tongue
- treat the same as strep pharyngitis with penicillin vs azithro if allergy hx
- the skin will initially peel following treatment
- How are the jones criteria used to diagnose rheumatic fever?
- What are the major jones criteria?
- What are the minor jones criteria?
- Dx of rheumatic fever is made if 2 major criteria are satisfied with hx of strep infxn or at least 2 minor criteria and 1 major criteria are met with history of a strep infection
- Major criteria-carditis, sydenham’s chorea, subQ nodules, arthritis, erythema marginatum (annular rash)
- Minor criteria-fever, arthralgia, increased PR interval on EKG, elevated acute phase reactants (leukocytosis, CRP, ESR), family hx of rheumatic heart disease
- What are the Kocher criteria?
- How are they useful prognostically?
- These are 4 criteria used to predict the probability that a patient has septic arthritis, the criteria are:
1) non-weight-bearing
2) fever >38.5C
3) ESR > 40 mm/hr
4) WBC >12k cells/mm3 - Prognostically, 1 criteria=3% probability, 2 criteria=40% criteria, 3 criteria=93% probability, and 4 criteria=99% probability.
-How should you manage a patient you suspect of having a septic joint?
- Obtain CBC/ESR/ultrasound of the extremity
- Consult ortho for possible aspiration vs OR
- What causes Dengue Fever?
- What is the spectrum of illness of Dengue Fever?
- What are sxs/PE findings?
- How is it diagnosed?
- What would you see on CBC+coags?
- How is managed?
- Viral illness spread mosquito vector in an endemic region (travel travel travel)
- Can present from mild febrile illness to frank hemorrhagic shock.
- Sxs include fever, headache, arthralgia/myalgia, abdominal pain, NVD, petechial rash. On PE you may see tourniquet sign-petechial rash underlying blood pressure cuff or other evidence of spontaneous bleeding
- Viral PCR can detect it but you will likely get a CBC+coags given the sxs which will show thrombocytopenia, elevated hematocrit, and elevated PTT
- Manage shock/resuscitate as appropriate. There is no curative therapy-this patient needs supportive care and ICU admission for frequent labwork and serial monitoring
How should you interpret urine culture results?
-Any bacterial growth of 50,000 or more CFU of a single organism in a catheterized urine sample is confirmatory of UTI. In a voided urine sample (bag or clean-catch), more than 100,000 CFU is considered significant; however, growth of more than one organism on the urine culture suggests contamination.
- What common organism in septic arthritis should you always consider covering for?
- Why?
- What antibiotic would you use?
- Kingella kingae is a common cause of septic arthritis and osteomyelitis in infants and toddlers.
- Kingella kingae is difficult to isolate on typical culture media; polymerase chain reaction assays improve the diagnostic yield significantly; if polymerase chain reaction is unavailable, coverage for Kingella should be considered in cases of culture-negative septic arthritis in children younger than 4 years.
- Rocephin ftw! (Ampicillin-sulbactam or a first-, second-, or third-generation cephalosporin)
